2026 Richmond Conference Registration - Guests "*" indicates required fields Name*TitleCompany/Firm NameAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneHow Did You Hear About This Conference (Eagle Member Name or Other Communication)?This field is hidden when viewing the formDo You Require a Hotel Room (register by March 16th): Yes No This field is hidden when viewing the formHotel Arrival Date MM slash DD slash YYYY This field is hidden when viewing the formHotel Departure Date MM slash DD slash YYYY This field is hidden when viewing the formSpecial Hotel RequestsNOTE: Room reservations are made by completing this form, not directly with the hotel. Payment will be made by presenting a credit card at check-in. Room Rate: $295 Check In: 4PM Check Out: 12PMWill you attend the seminar? Yes No Will you attend the cocktail hour at The Jefferson? Yes No Will you attend the dinner at The Jefferson? Yes No Adjuster CE Credits pending for Florida, Texas and North Carolina. Please provide the following information:Name as it Appears on Your Adjuster LicenseFlorida Adjuster License #Texas Adjuster License #North Carolina Adjuster License #Legal CE Credits pending for Illinois, Virginia and Wisconsin. Please provide the following information:Name as it Appears on Your Legal LicenseIllinois Legal License #Virginia Legal License #Wisconsin Legal License #Do you require a Certificate of Attendance to submit to your Bar as an individual? Yes No Producer/Agent CE Credits pending for Florida, Texas and North Carolina. Please provide the following information:Name as it Appears on Your Producer/Agent LicenseFlorida Producer/Agent License #Texas Producer/Agent License #North Carolina Producer/Agent License #
